Use of gentamicin-impregnated beads or sponges in the treatment of early acute periprosthetic joint infection: a propensity score analysis

Antibacterial hydrogel coating is associated with lower complication risks after complex high-risk primary and cementless hip revision arthroplasty : a retrospective matched cohort study

Aims

This study aimed to verify the hypothesis that an antibiotic-loaded hydrogel, defensive antimicrobial coating (DAC), reduces overall complication and infection rates when used for high-risk primary and revision total hip arthroplasty (THA).

Methods

This was a retrospective, 1:1 matched cohort study of 238 patients, treated with cementless implants coated with and without DAC. A subgroup analysis was also conducted of patients undergoing second-stage revision THA for periprosthetic joint infection (PJI). Reinfection rates within two years, complications necessitating surgical intervention, and radiological analysis for aseptic loosening were assessed.

Results

Overall, the mean age of the patients was 68.3 years (SD 11.5), with 39 (32.8%) McPherson class A, 64 (53.8%) class B, and 16 (13.4%) class C. Four (3.4%) patients in the DAC group developed complications including one PJI and one delayed wound healing, while 13 (10.9%) patients in the control group developed complications, including five PJIs and three delayed wound healing (p = 0.032). PJI rates (p = 0.136) and delayed wound healing rates (p = 0.337) were not statistically significant. For second-stage revision THA, for PJI there were 86 patients in the DAC group and 45 in the control group. One patient (1.2%) in the DAC group developed complications with no recurrences of infection or delayed wound healing, while ten patients (22.2%) in the control group developed complications including four recurrent PJI and one delayed wound healing (p = 0.003). Recurrent PJI rates were statistically significant (p = 0.005), while delayed wound healing rates were not (p = 0.165). Patients treated with DAC also had lower rates of aseptic loosening (0% compared with 6.7%; p = 0.015). No local or systemic side effects related to the DAC hydrogel coating were observed.

Conclusion

Antibiotic-impregnated hydrogel coatings on cementless implants appear to be associated with decreased complication rates after complex primary or revision THA. For second-stage revision THA for PJI, it is also associated with reduced risk of reinfection and aseptic loosening.

Optimizing debridement and implant retention in acute periprosthetic joint infections

Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Editorial: Management of PJI/SSI after joint arthroplasty

The management of periprosthetic joint infection (PJI) and surgical site infection (SSI) after joint arthroplasty poses a major challenge in orthopedic surgery. This Editorial provides an overview of the studies published in the special issue "Management of PJI/SSI after Joint Arthroplasty", summarizing the key findings from these studies, which cover a wide range of topics, including stringent preventive strategies, comprehensive diagnostic methods, and personalized treatment modalities. The authors concluded the editorial with their perspectives regarding the status quo of research in this field and future directions for research, such as the development of novel antibiotics, biofilm research, patient-specific risk factors, and the integration of technological advancements (such as machine learning and artificial intelligence) into clinical practice. The authors emphasized the need for continued research, interdisciplinary collaboration, and the application of innovative technologies to enhance patient outcomes and mitigate the burden of these infections on healthcare systems.

A protocol for periprosthetic joint infections from the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands

Periprosthetic joint infection (PJI) is a devastating complication of joint arthroplasty surgery. Treatment success depends on accurate diagnostics, adequate surgical experience and interdisciplinary consultation between orthopedic surgeons, plastic surgeons, infectious disease specialists and medical microbiologists. For this purpose, we initiated the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands in 2014. The establishment of a mutual diagnostic and treatment protocol for PJI in our region has enabled mutual understanding, has supported agreement on how to treat specific patients, and has led to clarity for smaller hospitals in our region for when to refer patients without jeopardizing important initial treatment locally. Furthermore, a mutual PJI patient database has enabled the improvement of our protocol, based on medicine-based evidence from our scientific data. In this paper we describe our NINJA protocol.

Level of evidence: III

A Preliminary Exploration of the Efficacy of Gentamicin Sponges in the Prevention and Treatment of Wound Infections

Purpose

This study aimed to construct drug-loading and drug-releasing quantitative equations for gentamicin sponges in addition to realizing a gentamicin sponge for wound infection prevention and treatment.

Methods

Sterile sponges were cut into pieces of 1×1 × 0.5 cm and immersed in 40, 16, 8, 4, 1.6, 0.8, or 0 mg/mL of gentamicin solution for 12, 24, 48, 96, or 120 h to evaluate their gentamicin loading. The sponges were subsequently immersed in the gentamicin solution of different concentrations for 48 h, air-dried, and then immersed in 10 mL of 0.9% physiological saline to evaluate the gentamicin release. Methicillin-sensitive Staphylococcus aureus (MSSA) and Pseudomonas aeruginosa were used to explore the sponges’ infection prevention scheme. In addition, a rat femur fracture with wound infection model was used to assess the infection treatment scheme.

Results

The antibacterial zone sizes of the sponges immersed in 40, 16, 8, 4, 1.6, and 0.8 mg/mL of the gentamicin solution were larger than those of the 0 mg/mL air-dried sponge, and the difference was statistically significant (p < 0.01, p < 0.01, p < 0.01, p < 0.01, p < 0.01, and p < 0.01, respectively). The rats in the 40, 16, and 8 mg/mL air-dried sponge groups had no wound suppuration in either the MSSA or P. aeruginosa rat infection models.

Conclusion

A quantified equation for the sponges’ gentamicin loading and release was achieved with high accuracy. Furthermore, we recommend the 40, 16, or 8 mg/mL air-dried sponge for the treatment of wounds with antibiotic-sensitive bacterial infections.

New developments and future challenges in prevention, diagnosis, and treatment of prosthetic joint infection

Prosthetic joint infection (PJI) is a devastating complication that results in substantial costs to society and patient morbidity. Advancements in our knowledge of this condition have focused on prevention, diagnosis, and treatment, in order to reduce rates of PJI and improve patient outcomes. Preventive measures such as optimization of patient comorbidities, and perioperative antibiotic usage are intensive areas of current clinical research to reduce the rate of PJI. Improved diagnostic tests such as synovial fluid (SF) α-defensin enzyme-linked immunosorbent assay, and nucleic acid-based tests for serum, SF, and tissue cultures, have improved diagnostic accuracy and organism identification. Increasing the diversity of available antibiotic therapy, immunotherapy, and alternative implant coatings remain promising treatments to improve infection eradication in the setting of PJI.

High dose of vancomycin plus gentamicin incorporated acrylic bone cement decreased the elution of vancomycin

Purpose

Low doses of vancomycin and gentamicin were commonly incorporated into acrylic bone cement (antibiotic-impregnated bone cement, AIBC) during revision arthroplasty. Previous studies showed that only a very small amount of antibiotics could be eluted from AIBC. Given the fact that a high dose of antibiotic would elute high concentration of antibiotic, this study investigated the influence of a high dose of dual-antibiotic loading on the properties of cement.

Methods

A total of 8 groups of AIBC containing either gentamicin or vancomycin or both with different amounts of antibiotics (1 g, 2 g and 4 g) were tested on material properties, elution profiles, antibacterial activity and cytological toxicity.

Results

A high dose of gentamicin and vancomycin AIBC (with 2 g gentamicin and 2 g vancomycin loaded) regiment showed acceptable compressive strength of 74.25±0.72 MPa. No cytotoxicity or antibacterial activity reduction was observed in any group tested in this study. The elution profiles indicated that incorporating 2 g vancomycin resulted in 4.77% (1049.57±3.74 μg) released after 28 days. However, after 2 g gentamicin was added, the vancomycin released was significantly reduced to 2.42% (532.24±1.77 μg) (p<0.001), approximately 50% reduction. No significant influence of vancomycin on gentamicin was observed.

Conclusion

These findings suggest that the addition of 2 g vancomycin and 2 g gentamicin into acrylic bone cement was preferred while considering this dual-antibiotic AIBC regiment with acceptably material properties and effective antibacterial activity. However, special attention should be drawn to the reduction of vancomycin elution when incorporated with gentamicin.